Lessons from Countries Phasing Down Dental Mercury Amalgam Filling Use

Despite the broad challenges inherent in reducing amalgam use in dentistry, some countries have already considerably restricted or banned its use. While every country needs to develop an approach that is appropriate to its own circumstances, the various measures described below may provide inspiration to other governments taking steps to phase down the use of amalgam in their own populations. As cited in the country responses to the survey questionnaire, the main factors that have contributed to a decline in amalgam use include national and/or individual environmental concerns, patient and professional preferences to avoid mercury, patient preferences for tooth-colored fillings, professional preferences to favor viable techniques that preserve as much of the natural tooth structure as possible, etc. Moreover, oral health and dental hygiene programs that reduce the overall incidence of dental caries have also contributed to a decline in the need for dental restorations – both amalgam and non-amalgam (WHO 2011).

Please use the map below to see the experiences of the various countries that responded to the survey questionnaire which are summarized below.

SWEDEN

During the 1980s an intense debate was raised in the Swedish media by patient groups concerned about the health effects of amalgam in Sweden. Environmental concerns were also increasingly noted. Various expert groups and investigations were convened, and in 1991 the National Board of Health and Welfare investigated the preconditions for eliminating the use of dental amalgam (KemI 2005). In 1995 there was a voluntary agreement between the state and county councils to put an end to amalgam use in dental restorations for children and young people. However, by 1997 the voluntary measures had not achieved the objective that had been established. In 1999 the Swedish Parliament decided that patients should no longer be reimbursed for the cost of amalgam fillings under the national healthcare system. As a result, the cost to patients for amalgam became comparable to the cost for composites (KemI 2005). Figure 3 reflects the decline in amalgam use in Sweden since the 1970s. Since 2009 there has been a general ban on mercury in Sweden that includes dental amalgam. Meanwhile the cost of mercury-free restorations has continued to decline with new technologies, and with further training and experience of dental practitioners.

NORWAY

Interest in reducing amalgam use in Norway emerged during the 1980s as part of a broader policy to limit all releases of mercury, and also due to health concerns raised in the media by a patient association. In 1991, Norway issued guidelines that the use of amalgam should be limited due to environmental impacts. Stronger guidelines were issued in 2003, requiring materials other than amalgam to be considered as the first choice in tooth fillings. Since 2008 Norway has had a general ban on mercury products. This included a ban on amalgam, with an exemption period – now expired – for special cases. Amalgam use has been eliminated since 2011.

DENMARK

The sale of mercury has been forbidden in Denmark since 1994, but an exemption was initially granted for mercury in dental amalgam. A subsequent "Recommendation” of the Danish health authority stipulated that from 1999 amalgam fillings should not be placed in front teeth or “milk teeth,” nor should it be generally used for dental care of children. The health authority recommended that mercury-free alternatives should be the first choice for new fillings, except where: 1) it is not possible to keep the area dry; 2) it is difficult to access the cavity; 3) there is a particularly large cavity; or 4) the distance to the proximate tooth is too great. By 2013 amalgam was used in only 5% of restorations.

FINLAND

After consultation with an expert group in 1993, Finland issued the following recommendations: the use of amalgam should be reduced for environmental reasons and amalgam should be used only when other dental filling materials cannot be used. Since 1994 Finland’s national guidelines stipulated that amalgam should not be used in restorations. The use of amalgam has declined significantly, recently accounting for no more than 3% of dental restorations.

NETHERLANDS

In the Netherlands a major shift away from amalgam took place in the 1990s after consultation with the dental sector, which eventually embraced the use of mercury-free dental restorations. Consequently, the average use of amalgam in the 2000s was around 7% of all dental restorative fillings, dropping to less than 1% by 2011.

JAPAN

Since the 1980s Japan has moved almost completely away from amalgam for aesthetic and environmental reasons. Amalgam has been replaced by composite resin, glass ionomer and gold/silver/palladium alloy. Amalgam was used in approximately 11% of all dental restorations in the 1980s, declining to less than 4% in the 1990s. In 2010 only 20 kg of mercury were used in dentistry.

HUNGARY

In 2012 amalgam was reportedly used in only around 12% of all fillings placed in Hungary.

SINGAPORE

reported that amalgam was used in about 16% of all dental restorations in 2012. This map unfortunately shows all of Malaysia, when the above stats are just for Singapore

BANGLADESH

Mercury free dental amalgam by 2018

By Mohammad Al-Masum Molla

Environment and Social Development Organisation (ESDO) and Bangladesh Dental Society (BDS) have signed a Memorandum of Understanding (MoU) in a bid to eliminate “Mercury Dental Amalgam” from the dentistry sector in Bangladesh by 2018.The MoU was signed on Wednesday with the aim to promote policy advocacy for adaptation and institutional initiatives for “Mercury-Free Dentistry.” In the MoU, BDS and ESDO promised to work together to ensure mercury-free dentistry and ultimately a mercury-free environment.The objectives of the MoU are to support improving policy and facilitate the development and adoption of legislations to eliminate mercury amalgam totally from dentistry by 2016-2017 as per the country's situation; promotion of access to alternative filling materials by improving systems of governance on development related mobility; strengthen intra and inter-country multi-sectoral collaboration in association with ESDO and Asian Centre/WAMED, including all the members of BDS all over the country.Professor Dr MD Abul Kashem, president of the BDS, expressed his strong willingness to drive mercury consumption level to zero in order to make mercury free amalgam in Bangladesh. He also suggested raising awareness among medical teachers, practitioners and stakeholders about the harmful effects of mercury. Syed Marghub Murshed, former secretary and chairperson of ESDO, said the use of mercury has a harmful impact on the environment, public health and aesthetics. Dr Shahriar Hossain shared his miserable experience as he is one of the worst sufferers of mercury poisoning and expressed his expectation to BDS to work hand in hand to put a stop to this toxic element in dental amalgam.Secretary General of Bangladesh Dental Society Humayun Kabir Bulbul and Executive Director of ESDO Siddika Sultana signed the MoU on behalf of two organisations.- See more at: http://www.dhakatribune.com/bangladesh/2016/apr/27/mercury-free-dental-amalgam-2018#sthash.2MNoRZXU.dpuf

Countries that have Phased Down Dental Mercury Amalgam Fillings

SWEDEN

During the 1980s an intense debate was raised in the Swedish media by patient groups concerned about the health effects of amalgam in Sweden. Environmental concerns were also increasingly noted. Various expert groups and investigations were convened, and in 1991 the National Board of Health and Welfare investigated the preconditions for eliminating the use of dental amalgam (KemI 2005). In 1995 there was a voluntary agreement between the state and county councils to put an end to amalgam use in dental restorations for children and young people. However, by 1997 the voluntary measures had not achieved the objective that had been established. In 1999 the Swedish Parliament decided that patients should no longer be reimbursed for the cost of amalgam fillings under the national healthcare system. As a result, the cost to patients for amalgam became comparable to the cost for composites (KemI 2005). Figure 3 reflects the decline in amalgam use in Sweden since the 1970s. Since 2009 there has been a general ban on mercury in Sweden that includes dental amalgam. Meanwhile the cost of mercury-free restorations has continued to decline with new technologies, and with further training and experience of dental practitioners.

NORWAY

Interest in reducing amalgam use in Norway emerged during the 1980s as part of a broader policy to limit all releases of mercury, and also due to health concerns raised in the media by a patient association. In 1991, Norway issued guidelines that the use of amalgam should be limited due to environmental impacts. Stronger guidelines were issued in 2003, requiring materials other than amalgam to be considered as the first choice in tooth fillings. Since 2008 Norway has had a general ban on mercury products. This included a ban on amalgam, with an exemption period – now expired – for special cases. Amalgam use has been eliminated since 2011.

DENMARK

The sale of mercury has been forbidden in Denmark since 1994, but an exemption was initially granted for mercury in dental amalgam. A subsequent "Recommendation” of the Danish health authority stipulated that from 1999 amalgam fillings should not be placed in front teeth or “milk teeth,” nor should it be generally used for dental care of children. The health authority recommended that mercury-free alternatives should be the first choice for new fillings, except where: 1) it is not possible to keep the area dry; 2) it is difficult to access the cavity; 3) there is a particularly large cavity; or 4) the distance to the proximate tooth is too great. By 2013 amalgam was used in only 5% of restorations.

FINLAND

After consultation with an expert group in 1993, Finland issued the following recommendations: the use of amalgam should be reduced for environmental reasons and amalgam should be used only when other dental filling materials cannot be used. Since 1994 Finland’s national guidelines stipulated that amalgam should not be used in restorations. The use of amalgam has declined significantly, recently accounting for no more than 3% of dental restorations.

NETHERLANDS

In the Netherlands a major shift away from amalgam took place in the 1990s after consultation with the dental sector, which eventually embraced the use of mercury-free dental restorations. Consequently, the average use of amalgam in the 2000s was around 7% of all dental restorative fillings, dropping to less than 1% by 2011.

JAPAN

Since the 1980s Japan has moved almost completely away from amalgam for aesthetic and environmental reasons. Amalgam has been replaced by composite resin, glass ionomer and gold/silver/palladium alloy. Amalgam was used in approximately 11% of all dental restorations in the 1980s, declining to less than 4% in the 1990s. In 2010 only 20 kg of mercury were used in dentistry.

HUNGARY

In 2012 amalgam was reportedly used in only around 12% of all fillings placed in Hungary.

SINGAPORE

reported that amalgam was used in about 16% of all dental restorations in 2012. This map unfortunately shows all of Malaysia, when the above stats are just for Singapore

BANGLADESH

Mercury free dental amalgam by 2018

By Mohammad Al-Masum Molla

Environment and Social Development Organisation (ESDO) and Bangladesh Dental Society (BDS) have signed a Memorandum of Understanding (MoU) in a bid to eliminate “Mercury Dental Amalgam” from the dentistry sector in Bangladesh by 2018.The MoU was signed on Wednesday with the aim to promote policy advocacy for adaptation and institutional initiatives for “Mercury-Free Dentistry.” In the MoU, BDS and ESDO promised to work together to ensure mercury-free dentistry and ultimately a mercury-free environment.The objectives of the MoU are to support improving policy and facilitate the development and adoption of legislations to eliminate mercury amalgam totally from dentistry by 2016-2017 as per the country's situation; promotion of access to alternative filling materials by improving systems of governance on development related mobility; strengthen intra and inter-country multi-sectoral collaboration in association with ESDO and Asian Centre/WAMED, including all the members of BDS all over the country.Professor Dr MD Abul Kashem, president of the BDS, expressed his strong willingness to drive mercury consumption level to zero in order to make mercury free amalgam in Bangladesh. He also suggested raising awareness among medical teachers, practitioners and stakeholders about the harmful effects of mercury. Syed Marghub Murshed, former secretary and chairperson of ESDO, said the use of mercury has a harmful impact on the environment, public health and aesthetics. Dr Shahriar Hossain shared his miserable experience as he is one of the worst sufferers of mercury poisoning and expressed his expectation to BDS to work hand in hand to put a stop to this toxic element in dental amalgam.Secretary General of Bangladesh Dental Society Humayun Kabir Bulbul and Executive Director of ESDO Siddika Sultana signed the MoU on behalf of two organisations.- See more at: http://www.dhakatribune.com/bangladesh/2016/apr/27/mercury-free-dental-amalgam-2018#sthash.2MNoRZXU.dpuf